A Case of Candidemia after Long-term Presence of Urethral Foreign Bodies.

A 52-year-old man presented to our hospital complaining of general malaise, cough, and fever. Total body computed tomography revealed scattered pneumonia and urethral foreign bodies that had been inserted during adolescence. Candida glabrata was detected in blood and urine cultures. Based on these findings, the patient was diagnosed with candidemia that developed due to Candida urinary tract infection, complicated by septic pulmonary embolism and severe diabetes mellitus. Candidemia likely persisted despite the initiation of intravenous antifungal therapy and control of blood sugar level. Therefore, surgical removal of the urethral foreign bodies was performed, which resulted in resolution of the patient's symptoms. Herein, we report a rare case of candidemia complicated by Candida urinary tract infection that developed due to the long-term presence of urethral foreign bodies. A multidisciplinary therapeutic approach, including surgical removal of the infected foreign bodies, is effective in such cases. This case indicates that long-term presence of foreign bodies and acquired immune dysfunction can be risk factors for candidemia. Therefore, detailed history should be obtained and systemic examination should be performed to identify the complicating risk factors on diagnosis of candidemia.

Repeated spontaneous migration of ureteral stent in hemiplegia patient during ureteral stone treatment.

A 48-year-old man with a history of cerebral infarction presented with gross hematuria. The patient's limping accompanies twisting trunk on his walking. The diagnosis was right upper ureteral stone. Prior to Extracorporeal shockwave lithotripsy (ESWL) ureteral stent was inserted. After the second ESWL ureteral stent was displaced upwardly without patient's unknown. Retrograde intrarenal surgery (RIRS) was performed for both removal of ureteral stent and fragmentation of residual stone. Spontaneously, post RIRS ureteral stent was migrated upwardly to the same position. Ureteral stent migration is uncommon. Twisting walk may cause the position of ureteral stent upwardly.

[A Case of Consciousness Disturbance Due to Hyperammonemia Associated with Urinary Tract Infections].

We describe the case of a patient with hyperammonemia owing to urinary tract infections. The patient, a 66-year-old-woman, was previously diagnosed with bilateral hydronephrosis. She was admitted to the emergency room with macrohematuria and bilateral lumbar pain, which persisted for 2 days. She was hospitalized with the diagnosis of pyelonephritis. Despite antibiotic treatment, she developed sudden disturbance in consciousness on the 2nd day of illness. To improve the hyperammonemia and metabolic acidosis, we initiated continuous hemodiafiltration (CHDF) and urinary drainage by bilateral nephrostomy, after which her consciousness improved, and she was discharged on day 19. For patients with urinary tract infections and who are unaware of disturbance in consciousness, it is important to consider that obstructive urinary tract infections can cause hyperammonemia.

Development and external validation of a nomogram to predict high-grade papillary bladder cancer before first-time transurethral resection of the bladder tumor.

BACKGROUND: The aim of this study was to identify the clinical predictors related to the risk of high-grade papillary bladder cancer before first-time transurethral resection of a bladder tumor (TUR-Bt), and to develop and validate a nomogram predicting the risk of high-grade papillary bladder cancer. METHODS: A retrospective clinical study of consecutive patients who underwent first-time TUR-Bt for papillary bladder cancer was performed. Medical records were reviewed uniformly, and the following data were collected: age, sex, episodes of urinary symptoms, tumor size, number of tumors, location of the largest tumor (lateral walls, base, posterior wall, dome, and anterior wall), tumor appearance (papillary or non-papillary, pedunculated or sessile), and urinary cytology. Data from 254 patients (Group A) were used for the development of a nomogram, while data from 170 patients (Group B) were used for its external validation. RESULTS: High-grade papillary bladder cancer was pathologically diagnosed in 51.6 and 74.6% of Group A and Group B patients, respectively. Based on univariable analyses in Group A, macrohematuria, tumor size, multiple tumors, appearance, and positive urinary cytology were selected as variables to incorporate into a nomogram. The AUC value was 0.81 for the internal validation (Group A), and 0.78 for the external validation (Group B). This novel nomogram can predict high-grade papillary bladder cancer accurately. CONCLUSIONS: The present nomogram can help clinicians calculate the probability in patients with bladder cancer before TUR-Bt and decide on earlier intervention and priorities for the treatment of patients diagnosed with bladder cancer.

Apparent diffusion coefficient value for estimating clinicohistological factors in bladder cancer including infiltration style and lymphatic invasion.

OBJECTIVE: To evaluate a role of apparent diffusion coefficient (ADC) values measured from diffusion-weighted imaging we investigated its association with clinicopathological tumor characteristics of bladder cancer. MATERIALS AND METHODS: Diffusion-weighted MRI at 1.5 Tesla using b-values of 0, 1000 s/mm(2) was taken before transurethral resection by 114 bladder urothelial tumor patients. ADC value was measured and its relationship with pathological factors including T stage, tumor grade, infiltration style (INF) and lymphatic invasion (ly) was analyzed. RESULTS: Median ADC value was significantly lower in Grade 3 than in Grade 1 (P < 0.001) or in Grade 2 (P = 0.002), in INFb than in INFa (P = 0.004), in INFc than in INFa (P < 0.001), in ly1 than in ly0 (P < 0.001) and lower in T2≦ than in T1≧ (P < 0.001), respectively. Receiver operating curve demonstrated the accuracy of detecting muscle invasive bladder cancer or ly+ by using area under curve (AUC), showing 0.758 and 0.748. CONCLUSION: ADC value is likely to serve as a useful biomarker showing clinicopathological characterictics of bladder cancer.

[Comparison of the Conventional Centrifuged and Filtrated Preparations in Urine Cytology].

The urine cytology test is one of the most important tools for the diagnosis of malignant urinary tract tumors. This test is also of great value for predicting malignancy. However, the sensitivity of this test is not high enough to screen for malignant cells. In our laboratory, we were able to attain a high sensitivity of urine cytology tests after changing the preparation method of urine samples. The differences in the cytodiagnosis between the two methods are discussed here. From January 2012 to June 2013, 2,031 urine samples were prepared using the conventional centrifuge method (C method) ; and from September 2013 to March 2015, 2,453 urine samples were prepared using the filtration method (F method) for the cytology test. When the samples included in category 4 or 5, were defined as cytological positive, the sensitivities of this test with samples prepared using the F method were significantly high compared with samples prepared using the C method (72% vs 28%, p＜0.001). The number of cells on the glass slides prepared by the F method was significantly higher than that of the samples prepared by the C method (p＜0.001). After introduction of the F method, the number of f alse negative cases was decreased in the urine cytology test because a larger number of cells was seen and easily detected as atypical or malignant epithelial cells. Therefore, this method has a higher sensitivity than the conventional C method as the sensitivity of urine cytology tests relies partially on the number of cells visualized in the prepared samples.

External validation and comparison of two nomograms predicting the probability of Gleason sum upgrading between biopsy and radical prostatectomy pathology in two patient populations: a retrospective cohort study.

The aim of this study is to validate and compare the predictive accuracy of two nomograms predicting the probability of Gleason sum upgrading between biopsy and radical prostatectomy pathology among representative patients with prostate cancer. We previously developed a nomogram, as did Chun et al. In this validation study, patients originated from two centers: Toho University Sakura Medical Center (n = 214) and Chibaken Saiseikai Narashino Hospital (n = 216). We assessed predictive accuracy using area under the curve values and constructed calibration plots to grasp the tendency for each institution. Both nomograms showed a high predictive accuracy in each institution, although the constructed calibration plots of the two nomograms underestimated the actual probability in Toho University Sakura Medical Center. Clinicians need to use calibration plots for each institution to correctly understand the tendency of each nomogram for their patients, even if each nomogram has a good predictive accuracy.

Bilateral Ureteral Obstruction and Acute Renal Failure in Spite of Prior Ureteral Catheterization in Radical Hysterectomy.

We present an extremely rare case of acute renal failure following radical hysterectomy although we inserted ureteral catheter bilaterally. A 76-year old female received bilateral ureteral catheterization prior to operation. Just after operation oliguria was admitted and serum creatinine level increased to 3.6 mg/dL. An abdominal computed tomography (CT) revealed bilateral hydronephrosis. From soon after exchange to double J catheter large amount of urine was collected and the level of creatinine normalized 2 days later. The shape of J catheter may be more effective than open-end catheter because it has multiple side hole and can ensure urinary drainage.

[An infected renal cyst communicating with the urinary tract: a case report].

A 36-year-old man presented with fever and right backache. Abdominal computed tomographic scan revealed a right renal cyst, with a maximum diameter of 12 cm, and surrounded by a hyperdense area of perirenal fat tissue. The cyst appeared to be infected. Accordingly, we performed a percutaneous puncture of this cyst, and drained the fluid. The brown and cloudy fluid gradually became clear, the fluid volume increased a few days after the drainage. A communication between the infected cyst and urinary tract was suspected ; retrograde pyelography confirmed the presence of fistulas. The urine was drained, ＞ 600 ml per day, for four weeks. Surgical resection of the cyst wall and closure of the fistulas were performed as an additional treatment. A year after the open surgical procedure, the renal cyst did not recur, and his renal function has been normal.

[Clinical impact of peripheral lymphocyte counts for metastatic urothelial carcinoma patients treated with chemotherapy].

Pre-chemotherapeutic factors to assess the prognosis of patients with advanced urothelial carcinoma have not yet been completely established. The immune response of the host to the tumor is lymphocyte dependent. However, the effect of lymphocytes on chemotherapy prognosis is unknown. In this study, we investigated the correlation between pre-chemotherapeutic lymphocyte counts and the clinical characteristics of urothelial carcinoma and determined the effectiveness of lymphocytes as a prognostic predictor for metastatic urothelial carcinoma treated with chemotherapy. Between April 2003 and March 2011, data from 34 patients with unresectable or metastatic urothelial carcinoma were retrospectively subjected to multivariate regression analysis to determine the patient characteristics with independent prognostic significance for survival. The median patient age was 71 ; 21 patients were male and 13 female. The number of primary tumors in the pelvis, ureter, and bladder were four, six, and 24, respectively. Seventeen patients underwent prior curative resections, and visceral metastases at chemotherapy were detected in 14 patients. The median lymphocyte count at chemotherapy was 1,292/ml. Cancer-specific survival was significantly lower in patients with lymphocyte counts ＜1,000/ml than in patients with lymphocyte counts ≥1,000/µl (p＝0. 001). During multivariate analysis, visceral metastasis and lymphocyte counts were independent factors for predicting poor prognosis. In addition, lymphocyte counts of ＜1, 000/ml or positive visceral metastases also affected survival. This information may be useful for identifying patients who are likely to benefit from chemotherapy.

[Syphilitic orchitis: a case report].

Tertiary syphilis is recently a rare disease in Japan. In this paper, we report a rare case of syphilitic orchitis. The patient was in his early forties. The left scrotal contents were swelling and a low echoic nodule measuring about 30 mm in diameter was detected on ultrasonography. Serum alpha fetoprotein, lactate dehydrogenase, and beta subunit of human chorionic gonadotropin were within the normal range, whereas Treponema pallidum hemagglutination assay and rapid plasma reagin were strongly positive. High orchiectomy was performed for suspicion of testicular tumor. Histological findings showed the non-specific inflammatory granuloma with lympho-plasmatic infiltration. It was diagnosed as granulomatous inflammation of left testis caused by syphilis.

[A case of carcinosarcoma of the urinary bladder].

A 66-year-old woman visited our hospital complaining of painful, irritative urinary symptoms and macroscopic hematuria. Cystoscopy revealed a non-papillary tumor covered with necrotic tissue on the right side of the posterior wall of the bladder. Transurethral resection was performed ; histologically, the tumor was found to be composed of carcinomatous and sarcomatous elements. The carcinomatous element consisted of urothelial and squamous cell carcinomas. The sarcomatous element was composed of osteosarcoma, chondrosarcoma and spindle cell sarcoma. Immunohistochemical examination showed that the carcinomatous component was positive for cytokeratin and the sarcomatous component was positive for S-100 protein. The patient underwent total cystectomy with ileal conduit under the diagnosis of carcinosarcoma. Pathological examination showed no residual tumor. She was followed up with no signs of recurrence or metastasis. Computed tomography (CT) at nine months following surgery showed no evidence of recurrence. However, thirteen months after the operation, she complained of lower abdominal pain, and CT demonstrated a bulky intrapelvic tumor and right hydronephrosis. Her condition worsened rapidly and she died one month later.

Interactions of urate transporter URAT1 in human kidney with uricosuric drugs.

AIM: Hyperuricaemia is a significant factor in a variety of diseases, including gout and cardiovascular diseases. The kidney plays a dominant role in maintaining plasma urate levels through the excretion process. Human renal urate transporter URAT1 is thought to be an essential molecule that mediates the reabsorption of urate on the apical side of the proximal tubule. In this study the pharmacological characteristics and clinical implications of URAT1 were elucidated. METHODS: Madin-Darby canine kidney (MDCK) cells stably expressing URAT1 (MDCK-URAT1) were established and examined the interactions of URAT1 with various drugs such as benzbromarone and its metabolites including 6-hydroxybenzbromarone, angiotensin-converting enzyme inhibitors, non-steroidal anti-inflammatory drugs and urate transport inhibitors including E3040 and probenecid. RESULTS: MDCK-URAT1 cells exhibited a time- and dose-dependent increase in urate uptake, with a Km value of 570.7 µmol/L. When an URAT1-green fluorescent protein fusion protein construct was expressed in MDCK cells, the protein was sorted mainly to the apical side of the membrane. The drugs except for captoril dose-dependently inhibited urate uptake mediated by URAT1, with half maximal inhibitory concentration (IC(50) ) values ranging 0.05-716 µmol/L. CONCLUSION: Comparing these IC(50) values with intratubular concentrations of unbound drugs in humans, it is thought that URAT1 is a target molecule of uricosuric drugs, including 6-hydroxybenzbromarone, probenecid, indomethacin and salicylate, to inhibit urate reabsorption in vivo. In addition, a cell line that stably expressing URAT1 could be a useful tool for the development of uricosuric drugs.

[A case of urachal carcinoma treated with S-1/CDDP combination chemotherapy].

No established treatment exists for urachal carcinoma,except curative resection,and its prognosis is poor. More than 80% of urachal carcinomas are adenocarcinomas. We report a case of advanced urachal carcinoma treated with S-1 and cisplatin combination (S-1/CDDP) chemotherapy. The patient,a 61-year-old woman,presented with macroscopic hematuria. A tumor was detected on the bladder dome and transurethral resection was performed. Histopathological findings indicated poorly differentiated adenocarcinoma. Serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels were 3.5 ng/ml and 140 U/ml respectively. Magnetic resonance images indicated an extension of this tumor to the retroperioneal space. Metastasis to her right ischium was suspected from bone scintigraphy results. The tumor was diagnosed as stage IVB (Sheldon's category) urachal carcinoma. After one cycle of S-1/CDDP chemotherapy,the size of the tumor on the bladder dome decreased,after which total cystectomy was performed. The surgical margin of the cystectomy specimen was negative for malignant cells,although poorly differentiated adenocarcinoma was still observed in this specimen. The findings of this study indicate that this therapy might be beneficial for treating advanced urachal carcinomas. This is the second report of successful treatment of advanced urachal carcinoma with S-1/CDDP chemotherapy.

[Case of malignant lymphoma of the prostate complicated with prostate adenocarcinoma].

A 68-year-old man was referred to our hospital with complaints of palpation, hematemesis and melena. Esophagogastroduodenoscopy revealed a huge ulcer in the stomach, and based on biopsy findings, he was pathologically diagnosed as having diffuse large B-cell type malignant lymphoma. A computed tomographic scan demonstrated prostatic enlargement and swelling of the left external iliac lymph nodes. Since his serum PSA level was 13.0 ng/ml, prostatic needle biopsy was performed. Histological findings revealed diffuse large B-cell type malignant lymphoma and moderately differentiated adenocarcinoma of the prostate. The patient achieved complete response after eight cycles of combination chemotherapy with rituximab cyclophosphamide, adriamycin, vincristine and predonisolone. At the same time of chemotherapy, androgen deprivation therapy was initiated. The current his PSA level is 0.2 ng/ml or less.

Incidence of inguinal hernia after prostate surgery: open radical retropubic prostatectomy versus open simple prostatectomy versus transurethral resection of the prostate.

Our objective was to determine the incidence of inguinal hernia (IH) after surgery for prostatic diseases. Medical records of 395 patients who underwent radical retropubic prostatectomy (RRP; n = 155), open simple prostatectomy (OP; n = 35), or transurethral resection of the prostate (TURP; n = 205) at the Chibaken Saiseikai Narashino Hospital from April 2000 to March 2007 were retrospectively evaluated. The incidence of IH was 23.9% in the RRP group, 18.9% in the OP group, and 2% in the TURP group. Overall, 91.9% in the RRP and 83.3% in the OP group developed an IH within 2 years postoperatively. The laterality of IH after open surgery was mainly on the right side. Subclinical IH were seen in 25% of RRP cases. The existence of subclinical IH was the only significant risk factor for postoperative IH in this analysis. Furthermore, OP and RRP procedures significantly increased the risk of postoperative IH compared with TURP. The hernia-free ratios were significantly lower after RRP and OP than after TURP (vs RRP: P < 0.001; vs OP: P < 0.001). Our findings confirm that a lower abdominal incision itself is associated with postoperative IH in patients undergoing prostate surgery. Attention must be paid to pre-existing subclinical IH through careful preoperative assessment. Patients should be followed for more than 2 years due to the high incidence of postoperative IH.

A novel role of the C-terminus of b 0,+ AT in the ER-Golgi trafficking of the rBAT-b 0,+ AT heterodimeric amino acid transporter.

The heterodimeric complex composed of rBAT (related to b(0,+) amino acid transporter), a single-membrane-spanning glycosylated heavy chain, and b(0,+)AT, a putative 12-membrane-spanning non-glycosylated light chain, is an amino acid transporter that mediates the activity of system b(0,+), a major apical transport system for cystine and dibasic amino acids in renal proximal tubule and small intestine. The C-terminus of b(0,+)AT has been proposed to play an important role in the functional expression of the heterodimeric transporters. In the present study, to reveal the roles of the C-terminus, we analysed b(0,+)AT mutants whose C-termini were sequentially deleted or replaced by site-directed mutagenesis in polarized MDCKII (Madin-Darby canine kidney II), non-polarized HEK-293 (human embryonic kidney-293) and HeLa cells. Although the deletion of C-terminus of b(0,+)AT did not affect the formation of a heterodimer with rBAT, it resulted in the loss of apparent transport function, owing to the failure of the plasma-membrane targeting of rBAT-b(0,+)AT heterodimeric complex associated with incomplete glycosylation of rBAT. A motif-like sequence Val(480)-Pro(481)-Pro(482) was identified in the C-terminus of b(0,+)AT to be responsible for the C-terminus action in promoting the trafficking of rBAT-b(0,+)AT heterodimeric complex from the ER (endoplasmic reticulum) to Golgi apparatus. This is, to our knowledge, the first demonstration of the active contribution of the C-terminus of a light-chain subunit to the intracellular trafficking of heterodimeric transporters. Because the motif-like sequence Val(480)-Pro(481)-Pro(482) is well conserved among the C-termini of light-chain subunits, common regulatory mechanisms could be proposed among heterodimeric amino acid transporters.

[Clinical impact of body mass index on prostate biopsy in patients with intermediate PSA levels].

From April 2005 to September 2007, 480 patients underwent transrectal prostate biopsy at our institution. The clinical data including age, serum prostate specific antigen (PSA) level, prostate volume and body mass index (BMI) were obtained, and the cancer detection rates and pathological findings were evaluated in 305 cases with a PSA concentration of 4.0 to 10.0 ng/ml. Prostate volume was calculated from magnetic resonance imaging (MRI) findings. The 305 patients were categorized according to their BMI into three groups (normal, less than 22 kg/m2 ; overweight, 22-25 kg/m2 ; and obese, more than 25 kg/m2). Cancer detection rates and histopathologic findings were compared between the groups. Multivariate logistic regression analysis was also performed. Prostate cancer was detected in 127 patients. No significant differences in BMI were observed between biopsy-positive and biopsy-negative cases (p = 0.965), and the detection rates of prostate cancer observed in the three groups were not significantly different. There was a significant association between BMI and the findings of high Gleason score (more than 4+3) (p = 0.048). BMI was not a contributory factor of prostate cancer detection for cases with intermediate PSA levels; however, patients with high BMI may have high-grade malignancy features.

[Regression of mucosa-associated lymphoid tissue lymphoma of the bladder after antibiotic therapy: a case report].

A 69-year-old woman presented with macroscopic hematuria and severe anemia. Cystoscopy revealed flat edematous mucosa with continuous bleeding. Transurethral coagulation and a biopsy of the urinary bladder were performed. Histopathological examination of the biopsy revealed non-Hodgkin's lymphoma of the mucosa-associated lymphoid tissue (MALT) type. Results of a computed tomography scan and gallium scintigraphy suggested that it was a primary malignant lymphoma of the urinary bladder. A urinary tract infection was found and she was treated with antibiotics for 2 weeks. Because of the detection of a Helicobacter pylori (HP) infection in the gastric mucosal biopsy specimens, the patient was subsequently administered HP eradication therapy. Consequently, the lymphoma disappeared and the woman has had no tumor recurrence for the past 25 months.